CurrentUnitedHealthcarePolicy N/A

Medicaid CPT/HCPCS Code Coverage and Non‑Covered Codes Policy

Defines UnitedHealthcare Community Plan's approach to which CPT and HCPCS codes are covered or not covered in Medicaid markets and directs providers to state-specific lists and benefit documents; applies to claims billed on CMS1500/UB04 and to Community Plan Medicaid products and providers.

Policy Summary

PayerUnitedHealthcare

PolicyMedicaid CPT/HCPCS Code Coverage and Non‑Covered Codes Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a prior authorization request when a non-covered code may be medically necessary to request coverage under benefit or contractual exceptions.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CMS1500/UB04Forms

Not payableCategory II stance

MultipleStates referenced

3/15/2026Recent activity

Coverage Rules and State Exceptions

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Coverage Rules and Exceptions

General coverage determination rules for CPT and HCPCS codes in Medicaid markets.

If a CPT or HCPCS code is not listed on a state's Medicaid fee schedule, it is considered not covered in that state's Medicaid market unless there is a benefit or contractual agreement with a negotiated rate.

If a code appears on a state fee schedule but is not on the CMS National Physician Fee Schedule (NPFS), it will be covered for that state's Medicaid market but remains subject to all UnitedHealthcare Community Plan reimbursement policies and may deny under another policy.

If a code is neither on the CMS NPFS nor on an individual state fee schedule, it will deny as not covered in that particular state unless there is a benefit or contractual agreement with a negotiated rate; codes not covered in any UnitedHealthcare Community Plan market will be listed on the UnitedHealthcare Community Plan Non-Covered Codes List.

Some Medicaid markets use a covered-code list instead of a non-covered list; for those states, any code not on the covered-code list will deny as not covered.

A non-covered code for a covered service may nonetheless be covered if found to be medically necessary through a prior authorization process, per state-specific benefit considerations.

Attachment and State Exceptions History

History of attachment updates and archival actions affecting covered and non-covered code lists.

Attachments (Covered Codes Lists and Non-Covered Codes Lists) have been updated repeatedly for specific states; examples include Covered Codes Lists updates for Indiana, Ohio, Minnesota, New Mexico, Texas, Arizona, Kansas, Arizona, and Wisconsin and Non-Covered Codes Lists updates for Colorado, Florida, Hawaii, North Carolina, New York, Virginia, Washington, Mississippi, Maryland, Missouri, Nebraska, Tennessee, and others.

History entries prior to specified dates have been archived multiple times (examples: entries prior to 1/12/2023 and entries prior to 11/24/2022), reflecting periodic archival of older attachment history.

State-specific attachment activity is ongoing with multiple policy version changes noted (examples dated across 2024–2025) updating Covered and Non-Covered Codes Lists for various states.

CPT / HCPCS Coding Guidance and Lists

Category II CPT CodesCPTNot Covered

Category II (xxxxF)

CPT Category II procedure codes (ending in F) are used for performance measurement and are not payable in UnitedHealthcare Community Plan Medicaid markets.

Covered Codes Lists (various states)mixed

No codes listed

Non-Covered Codes Lists (various states)mixedNot Covered

No codes listed

inv-06: Default coverage rule — Fee schedule requirement

Default ruleAny CPT/HCPCS code not on a state Medicaid fee schedule is considered not covered for that state's Medicaid market unless there is a benefit or contractual agreement with negotiated rates.

Benefit/contract overridesCodes absent from a state fee schedule may be covered if a contractual or benefit agreement with negotiated rates exists.

Provider responsibilityProviders must reference individual state provider manuals, state websites, or other regulatory materials to determine covered codes for that state.

Application scopeApplies to CPT and HCPCS codes billed for UnitedHealthcare Community Plan Medicaid products in the specified state market.

Provider Requirements and Prior Authorization

Prior Authorization

Prior authorization may override non-covered code status

A non-covered code for a covered service may be covered if found to be medically necessary through a prior authorization request. Providers should submit a prior authorization when clinical documentation supports medical necessity for services represented by codes that are not listed on a state's fee schedule or are otherwise designated as non-covered.

Applicable when a code is designated as non-covered on the state-specific lists
Do not submit solely because a code is missing from an Ohio Department of Medicaid fee schedule — include clinical rationale and supporting documentation

Note

State Exceptions update — North Carolina added

State-specific exceptions and lists are maintained and updated in the Attachments/Resources sections. North Carolina has been added to the State Exceptions section. Providers should consult the policy attachments for the current Covered Codes Lists and Non-Covered Codes Lists for their state prior to billing or submitting prior authorization.

North Carolina added to State Exceptions (see Resources / Attachments)
Recent updates to Covered/Non-Covered Codes Lists may affect billing — check attachments for Kansas, Minnesota, Arizona, Missouri, Nebraska, New Jersey, Maryland, Mississippi, New York, Ohio, Texas, Virginia, Washington, Washington DC, Wisconsin

Definitions and Attachments

inv-09: CPT Category II Procedure Codes

DefinitionCPT Category II Procedure Codes are identified by the procedure code ending with 'F' (format xxxxF).

PurposeCategory II codes are used primarily for performance measurements.

ExampleExample code format given: 1038F in the source document.

inv-10: Experimental or Investigational Services

DefinitionExperimental or Investigational Services are medical, surgical, diagnostic, psychiatric, substance abuse or other health care services, technologies, supplies, treatments, procedures, drug therapies, medications, or devices that at the time of coverage determination are not FDA-approved for the proposed use or are otherwise considered experimental.

FDA statusNot approved by the U.S. Food and Drug Administration to be lawfully marketed for the proposed use (and not identified in AHFS or USP dispensing information as appropriate).

Research oversightSubject to review and approval by any institutional review board for the proposed use (Humanitarian Use Device exemptions noted as not considered experimental).

inv-11: Attachments Section (Covered Codes Lists, Non-Covered Codes Lists)

Attachments includedAttachments Section contains Covered Codes Lists and Non-Covered Codes Lists which are updated periodically for specific states.

Update historyAttachment updates are logged in the Resources/History section with state-specific covered/non-covered list changes (examples: Indiana, Texas, Arizona, Kansas, Minnesota, Ohio, Wisconsin).

Archival practiceEntries prior to specified dates are archived as noted in the History entries (e.g., entries prior to 1/1/2024 or earlier archived on listed dates).

inv-12: State Exceptions (state-specific deviations or additions such as addition of North Carolina)

State Exceptions (example)State Exceptions section documents state-specific deviations or additions; North Carolina was explicitly added to the State Exceptions list (4/10/2024 entry).

Ongoing updatesState Exceptions and attachments are updated repeatedly with specific state changes noted in Resources (multiple dates in 2024-2025).

ImpactState-specific exceptions may change coverage behavior for codes in that state's Medicaid market; providers should consult the State Exceptions entries for applicable deviations.

Policy Revision and Attachment Update History

2025-01-01policy_version_change

Attachments Section: Covered Codes Lists updated for Indiana, Kansas and Ohio; Non-Covered Codes Lists updated for Hawaii, Maryland, Missouri, New Jersey, North Carolina, and New York; History entries prior to 1/12/2023 archived.

2024-12-15policy_version_change

Attachments Section: Covered Codes Lists updated for Arizona, Indiana, and New Mexico; Non-Covered Codes Lists updated for Mississippi, Missouri, Nebraska, North Carolina, and Washington.

2024-12-11policy_version_change

Non-Covered Codes Lists updated for Tennessee.

2024-12-08policy_version_change

Attachments Section: Covered Codes Lists updated for Indiana, Kansas, Texas, and Wisconsin; Non-Covered Codes Lists updated for Maryland, New York, and Virginia.

2024-11-24policy_version_changeLatest

Attachments Section: Covered Codes Lists updated for Minnesota, New Mexico, Ohio, and Texas; Non-Covered Codes Lists updated for Mississippi, North Carolina, and Virginia; History entries prior to 11/24/2022 archived.